Examination of the neck and head begins with inspection.
General aspects and inspection
Lesions and abnormalities of bone structure, soft tissues of the face are obvious but lesions in the scalp are often not apparent except in bald males. Anatomically, the neck is divided into two triangles on either side of the midline. Abnormalities of the neck are visible as swellings. Size and location should be noted and confirmed later by palpation. Lumps attached to the trachea, e.g. thyroid swellings, move upwards on swallowing. The most common lump in the neck is due to cervical lymphadenopathy, which may be inflammatory but is often neoplastic (secondary carcinoma or lymphoma).
An important feature of inspection of the neck and head relates to the venous drainage. Abnormal engorgement of the external jugular vein may be indicative of cardiac failure or circulatory overload. In patients with obstruction of the superior vena cava, usually caused by malignant lymphadenopathy in the superior mediastinum (primary or secondary), there is gross engorgement of the neck and head with prominent superficial veins, a congested suffused appearance and evidence of collateral pathways over the anterior chest wall.
Surgical emphysema most commonly appears in the neck and head region as soft crepitant diffuse swelling. It is caused by escape of air from lacerations or perforation of the tracheobronchial tree or the oesophagus. The extravasated air tends to occupy and cause swelling of regions with lax tissue planes, such as the supraclavicular and periorbital regions. When marked, the resultant swelling leads to virtual occlusion of the eyelids.
Systematic palpation of the scalp is essential to detect lesions in this region. Parting of the hair over a lump identified by palpation enables closer inspection of the lesion. Scalp lesions superficial to the galea aponeurotica move with the scalp when the patient contracts the occipitofrontalis muscle. Lesions deep to this structure or those invading it and the subjacent pericranium are fixed.
Palpation of the anterior triangles of the neck is carried out from the front, whereas palpation of the posterior triangles is best conducted from behind. The entire regions are covered and if an anterior lump is felt, the patient should be asked to swallow and any resulting displacement noted. The consistency of the lump is determined and fluctuation elicited if the swelling appears to be soft and cystic. Transillumination of a large cystic swelling in infants, if positive, confirms the presence of cystic hygroma. Palpation of the neck must cover the lymph node groups, especially the deep cervical and the supraclavicular regions. The left supra-clavicular region is a common site for metastatic nodal disease from visceral cancer (oesophagus, stomach and pancreas). The carotid vessels must also be palpated for thrills, associated swellings and any aneurysmal dilatation.
Percussion is seldom employed in examination of the neck and head. It may provide useful information in swellings occupying or extending below the suprasternal notch, when percussion over the manubrium may elicit dullness, indicating probable retrosternal extension of the lump. This is most often encountered with swellings of the thyroid gland. However, it is an imprecise clinical test and is unreliable, especially in patients with obstructive airways disease, emphysema.
Auscultation is used if the swelling appears to be vascular and is most commonly applicable to patients with toxic enlargement of the thyroid gland. A systolic bruit is often present in patients with primary hyperthyroidism. Auscultation of the carotid vessels should be performed routinely in patients above the age of 50 years and is mandatory in patients with a history of fleeting blindness (amaurosis fugax) or recoverable attacks of muscle weakness, loss of consciousness. These symptoms are indicative of ‘minor strokes’, which are referred to as transient ischaemic attacks (TLAs) and are caused by emboli from atheromatous narrowing of the carotid vessels at the bifurcation into external, internal carotid branches. In these patients a carotid bruit is often heard on auscultation.
Thyroid swellings are designated by the general term goitre and move on swallowing. Enlargement of the thyroid gland may be unilateral or diffuse and bilateral. If a discrete lesion is located in the isthmus of the gland, it presents as a midline swelling; otherwise the majority of unilateral swellings are lateral or anterolateral. They are commonly solid but may be cystic. Diffuse multinodular enlargement (nodular goitre) is common and associated with iodine deficiency. In some disorders such as primary hyperthyroidism the thyroid is uniformly enlarged with a smooth surface. A discrete solitary nodule in an otherwise normal thyroid should always raise suspicion of malignancy (papillary or follicular neoplasm) and must be accompanied by a systematic palpation of the neck to exclude or confirm associated lymphadenopathy. However, the anaplastic cancers encountered in older patients present as diffuse infiltrative enlargement of the thyroid. Because of fixation to surrounding tissue, the mass does not move with swallowing, may be accompanied by features indicative of tracheal compression (dyspnoea and stridor), involvement of the recurrent laryngeal nerve (hoarseness).
The position of the trachea should be checked in all patients with thyroid enlargement, and with large swellings the inferior part of the mass is palpated carefully to determine the lower margin. If this cannot be felt, a retrosternal prolongation is likely. A large benign goitre with a retrosternal extension can give rise to pressure symptoms such as engorgement of the head and neck veins and stridor. These are accentuated when the patient elevates both upper arms above the head. Clinical assessment of thyroid status (euthyroid, hyperthyroid or hypothyroid) is an integral part of the examination of a patient with thyroid enlargement.
Enlargement of the salivary glands
There are four major salivary glands: two parotid and two submandibular. The parotid gland has been likened to ‘a lump of bread dough poured over an egg whisk’, the dough representing the glandular tissue and the egg whisk the branches of the facial nerve. The gland occupies and extends over the hollow between the masseter muscle anteriorly and the stemomastoid posteriorly. It is covered with a dense parotid fascia, deep to which are attached the parotid lymph nodes.
In practice, enlargement most commonly affects the parotid gland, followed by the submandibular gland. Although swellings of the salivary glands may be due to viral infections (e.g. mumps parotitis), in surgical practice the enlargement is most commonly caused by calculous disease blocking the ductal drainage system (submandibular more commonly than parotid) or by tumours (predominantly mixed parotid tumours). Enlargements of the submandibular gland appear as swellings in the submandibular triangle. In contrast, parotid swellings occur within a large inverted triangular area with boundaries extending from the tragus of the ear to the anterior border of the mandibular ramus and the gap between the mastoid process and the angle of the mandible inferiorly. Swellings caused by infection and stones obstructing the salivary duct are painful and tender, whereas tumours are painless.
Face, oral cavity and scalp
Inspection forms an important part of the examination. The facial expression describes the mood of the patient and, with practice, the physician can rapidly establish anxiety, depression, introversion and mania. Inspection of the skin and mucosal surfaces, conjunctivae and buccal mucosae identifies pallor (anaemia), central cyanosis (deoxygenation of the blood and polycythaemia) and abnormal pigmentation. The yellowish discoloration in jaundiced patients is obvious on inspection but minor grades of icterus are identified by examination of the sclera in a good light. Other features of hepatic disease include muscle wasting, bruising, spider naevi found in the territory of the superior vena cava, and yellowish- white periocular fatty deposits (xanthelasma) encountered in certain hyperlipidaemic states.
The mucosal lining of the lips, buccal mucosa may exhibit areas of pigmentation in certain disorders. The most common ulcers of the lips are viral lesions (herpes simplex), which often accompany debility, infections of the upper respiratory tract and occur as painful lesions at the angle of the mouth. Malignant ulcers of the lip are squamous cell lesions that present as painless persistent ulcers, usually on the lower lip. Spread is to the submental, submandibular lymph node groups in the first instance. Basal cell carcinomas (rodent ulcers) are much more frequent and occur in elderly patients, predominantly in the upper third of the face and scalp above the maxillary line. The other common malignant tumour encountered in the face and scalp is malignant melanoma, of which there are various types. Malignant melanomas occur as pigmented lesions over a wide age range and are prevalent in fair-skinned individuals exposed to sunshine.
The buccal cavity is examined for gingival hypertrophy (often drug induced), inflammation (gingivitis) and tumours of the gums, and for lesions (ulcers, thickenings and fissures) of the tongue, buccal mucosa. Oral and mucocutaneous candidiasis (infestation by Candida albicans) is encountered in debilitated individuals and may complicate antibiotic therapy. The infection causes a very sore mouth and throat and may extend to the oesophagus. The affected mucosa is red, covered with white adherent patches. The pharynx can be inspected directly or indirectly with a laryngeal mirror and light source. Ulcers of the tongue should always be viewed with suspicion. While some are traumatic (caused by a jagged tooth or ill-fitting dentures) or aphthous in nature, a significant percentage prove to be malignant. As approximately one-third of cancers of the tongue occur on the undersurface or on the lateral edge of the posterior third of the tongue, examination should include elevation of the organ for inspection of the inferior surface and protrusion forwards and laterally (to either side), while the appropriate angle of the mouth is retracted to enable adequate inspection or the posterior part of the lateral borders.
The most common swelling of the scalp is a sebaceous cyst, which is a retention cyst of a hair follicle. Sebaceous cysts are often multiple. They are round in shape and always attached to the skin. Their contents are cheesy in nature and on palpation they are firm and non-fluctuant. Sometimes, a punctum can be identified in the centre of the lesion. They become painful and swollen if infected, when they discharge pus and then resolve, although recurrence of the swelling is frequent.